Provider Demographics
NPI:1225181035
Name:KASSAW, JON ED (MA LPCC)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:ED
Last Name:KASSAW
Suffix:
Gender:M
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 807
Mailing Address - Street 2:
Mailing Address - City:ESTANCIA
Mailing Address - State:NM
Mailing Address - Zip Code:87016-0807
Mailing Address - Country:US
Mailing Address - Phone:505-384-2777
Mailing Address - Fax:505-384-2204
Practice Address - Street 1:903C 5TH STREET
Practice Address - Street 2:
Practice Address - City:ESTANCIA
Practice Address - State:NM
Practice Address - Zip Code:87016-0807
Practice Address - Country:US
Practice Address - Phone:505-384-2777
Practice Address - Fax:505-384-2204
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0182191101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CCMH0182191OtherNM THERAP BOARD